Consultant, training and author in behavioral health.

Menu

Tag Archives: Practicum Training

A common issue that arises in my supervision with therapists in training is whether and when to disclose personal information to clients. There is no general rule about self-disclosure in psychotherapy, but it is important to be intentional and thoughtful in these decisions. This blog will describe different decisions I have made and how I reached those decisions.

One situation in which I chose to disclose was with a client who is about my age and who has a pervasive sense of rejection and inadequacy. She lives with a serious mental illness and receives psychiatric and supportive housing services from the county mental health system. She regularly perceives service providers as being condescending and treating her as inferior. Early in our treatment, she talked about concerns related to her teenage son, who she raised until he was ten and then gave guardianship to her brother when her mental illness became serious enough that it interfered with being consistently available as a parent. Her tendency was to personalize his focus on school and peer relationships and felt excluded by her son and her brother. I worked on this issue with her in many ways, but one aspect of our discussion was that I self-disclosed that I also had a teenage daughter and had experienced some of the same issues she described. My choice to disclose to her was based on my knowledge and experience that providing less personal information about adolescent development wasn’t reassuring to her because of the intensity of her sense of inadequacy. She was vulnerable to perceiving her son’s normal adolescent shift in attention and focus as a reflection of her inadequacy as a parent. We had worked together long enough for me to know that she respected me but also saw me as a peer who didn’t need to assert authority over her. I didn’t give her details about my relationship with my daughter, but simply shared that I was familiar with some of what she described due to having a daughter about the same age. She seemed reassured by this and became somewhat less self-critical and resentful. As time went on, she sometimes asked if I had experienced something she described and I answered her honestly. She didn’t pry for details and I didn’t volunteer more information than she asked, but it did seem to give her more confidence in my statements about the meaning of her son’s behavior.

A second situation in which I chose to self-disclose was when I felt a client needed to know the basis of a mistake I made in her therapy. A client who I had seen for a couple years stated she wanted to reduce her sessions to every other week, shortly after she gave birth to her second child. She said it was too hard to arrange her schedule to come every week, and I agreed to this change in our schedule. Uncharacteristically, I didn’t explore her decision in much detail or reflect myself on the multiple meanings this reduction in frequency might have for her. At the time of this interaction, I had recently become an empty nest parent after my younger child went to college. Part of my adaptation to this change in my life was to focus my attention on supporting my daughter’s independence and autonomy, despite my own feelings of sadness and loss. A couple months after my client had reduced her session frequency, I noticed that she was reporting high levels of stress and a return of symptoms that had been managed before her child’s birth. I mentioned this and said I thought we should consider returning to every week. My client expressed surprise that I had agreed to reduce her sessions and said “I don’t know why you did that” with some anger. In that moment, I made the connection between my personal empty nest adaptation and my hasty response to my client’s suggestion. I decided I needed to acknowledge my mistake and disclose my understanding of why I had made it. As in the previous example, I said only a couple sentences about the context and apologized. My client said “I thought there must be something going on; it’s not like you at all.” We returned to meeting each week, the client’s symptoms again improved, and we continued to work together productively.

In a third situation, my brief self-disclosure was in response to a question from a client. She was describing a relationship difficulty that was similar to something I had experienced in the previous few years. I didn’t disclose my experience, but I did use it in my response to her. I said something like “I can imagine you might feel…” and went on to describe my understanding of what was getting in her way. My client said “I have a feeling you’ve experienced something like this” and I responded “yes, I have.” She then returned to her feelings and conflicts and didn’t refer then or later to the parallel in our experience.

One of the common aspects of these three situations is that I had worked with each of these clients for at least six months. We had established a therapeutic alliance that was not based on my self-disclosure, and I had a good understanding of their issues and how they would respond to having personal information about me. It is more difficult, generally, to be confident about the impact of a self-disclosure when it occurs early in treatment. The potential for the client to feel distracted by knowing personal information, to feel the therapist has shifted the focus of attention away from the client, or to make incorrect assumptions about the meaning of the therapist’s self-disclosure are greater when the therapeutic alliance hasn’t been firmly established.

I hope these examples contribute to your consideration of self-disclosure in working with clients. I’m happy to get any feedback you’d like to share with me.

There are times in the life of a psychotherapist when our own life circumstances or recent events make it difficult or unwise to see clients with issues and needs that come too close to what we are dealing with personally. Decisions to limit our practice are individual and personal, and there aren’t any general rules to follow. In this blog post, I will share some of the issues that have arisen for me and the decisions I have made at different times in my professional practice.

As I was completing my post-graduate hours for licensure and anticipating the establishment of my independent practice, I made a decision to limit my practice to adult psychotherapy. I had some training in child and family therapy, though it was a minor focus for me. At the time I became licensed, I had two children and realized that my temperament was better suited to dealing with the complexities of parenting and child development in my personal life only. I enjoyed what was usually a somewhat less chaotic environment in my work with individual adults and couples, and it was helpful to not have the frequent need for consulting with other parties as is necessary when working with children and families while I was raising my own children. I was both a better mother and a better therapist by keeping that separation. When my children were older and out of the house, I saw a small number of adolescents as referrals came my way and I found it comfortable to take on the challenges of working with parents and children in that developmental life stage.

I came to a second decision when I faced a separation and divorce. I recognized that I felt less confident in working with couples as a result of the end of my marriage, and didn’t do any couple therapy for a period of a few years. When I felt I was ready to resume seeing couples, I got some training and consultation to add to my skill base and to ensure that I was looking clearly at the issues being presented by my couple clients. My work with individual adults has continued to be the primary focus of my work, but I have seen a small number of couples over the subsequent years.

Another decision that arose for me was related to a single client, when I initiated the end of therapy. I had worked with this individual for more than a year when she began coming to sessions with a pattern of regularly berating me and the therapy. She didn’t seem open to examining the origin of her feelings or to reflecting on the meaning of her anger toward and blame of me. I worked with this pattern for a number of weeks, then came to realize that I had begun to dread the sessions and to shut down my emotional openness to her and our therapeutic relationship. This troubled me, since I know that I use my emotional connection with the client as the most important aspect of the healing relationship between us. I worked with my sense of emotional distance but found I was unable to shift it. I didn’t feel safe being open with her when I was met so often with criticism and rage. This issue touched on experiences I had had in personal relationships, which I had resolved and were no longer active. However, the residue of those experiences as well as my own personality and interpersonal patterns didn’t allow me to move beyond my response of self-protection. I decided I couldn’t continue as her therapist, since I knew I wasn’t able to do my best work with her. I shared this decision with her, telling her that I had become aware that I wasn’t able to feel open and connected with her and under those circumstances, it wasn’t ethical for me to continue working with her. I acknowledged that this was an issue that was specific to me and that other therapists might not have the same response. She was unhappy and angry with my decision, but I remained clear and spent several sessions completing the therapy and providing recommendations for her to continue her work with someone else.

A final issue that came up in my practice more recently was when my father had a serious health crisis. At the time he became ill, I was in the early stage of work with a client whose father had died 4 months earlier. She was in a very intense state of grief and her therapy was completely focused on her father’s death. My father’s health crisis lasted a couple weeks after which he improved slowly over the next few months. I had a few sessions with this client in which I was somewhat preoccupied with the similarity between her situation and mine, but this lifted quickly. If my father had remained ill or had died, it would have been difficult for me to continue with this client. I’m not sure what I would have done, but I would have needed to consider whether I could provide the treatment she needed. Getting additional consultation might have helped, and increasing the frequency of my own psychotherapy would have been wise. If I decided that my own preoccupation was a serious interference, I would face a decision about whether ending the therapy was in the best interest of the client. Ending the therapy would have presented her with another loss, but continuing might not have provided her with the best care. More than likely, I would have explained the dilemma to my client and asked her to join me in thinking through what would be best for her.

I share these examples as illustrations of how I have navigated decisions about my practice based on events and issues in my personal life. Other therapists have navigated similar decisions in different ways. As I said earlier, there are no general rules. However, throughout our professional lives, we need to exercise our skills of self-awareness, seek consultation from trusted peers and mentors, and notice when our personal issues arise in our work with different clients.

I attended a writing workshop in Porto, Portugal in May 2018 and this led me to begin a new series of blogs that combine exploration of professional topics with reflections about my personal experience and life related to those topics. This series will be posted once a month, alternating with previously published posts. I look forward to your feedback on this new venture.

Personal psychotherapy is often required or recommended by training programs for psychotherapists. This provides an experiential perspective on psychotherapy, gives the student an opportunity to reflect and focus on unresolved issues that may arise in the training process, and serves as a support for the many questions and emotions that accompany the early stages of working as a therapist. My own psychotherapy journey has taken place across many years and has contributed greatly to my professional as well as personal growth.

My first experience as a client in psychotherapy was in graduate school. My program didn’t require personal psychotherapy, but most of my peers saw a therapist while they were enrolled in the program. I was in my 20’s, had given birth to my second child within the prior year, was beginning my third year of a demanding doctoral program, and had developed symptoms of depression a few months earlier. I recognize now that this was my third episode of depression, but at the time I was more aware of my painful feelings of despair and overwhelm than the clinical meaning of symptoms.

I had no exposure to psychotherapy of any kind before graduate school, and although I was in training to become a therapist, I held feelings of shame and fear about being vulnerable and acknowledging that I needed help. I initially kept my shame at bay by telling myself I was doing what everyone else in my program did, and I managed my fear by seeking therapy with someone who was known to other students in my department as both a therapist and a supervisor. My first impression of therapy was a feeling of amazement that someone would give me his full attention for the 50-minute session. I hadn’t had that experience before. My parents were overwhelmed with caring for three children under the age of 5 while they were in their mid-20’s, and the refuge of unconditional love I found at my grandparents’ house didn’t include talking about the things that troubled or concerned me.

My first therapist helped me identify the repetitive patterns I had carried from my childhood and encouraged me to try doing things differently. I examined the stringent expectations I held for myself as well as my pattern of only showing what I considered to be my strength and competence to others around me. I told a graduate school classmate that I was going to take the “stop and smell the roses” path for the rest of graduate school. It turned out that this didn’t delay in my progress toward graduation, but it did allow me to make active choices rather than being compelled by unexamined assumptions. Since that first experience I have returned to therapy a number of times, sometimes when the combination of life circumstances and my internalized patterns have resulted in distress beyond what I could manage on my own, and sometimes when I have identified areas of my internal and external life that I want to change with the support of someone wise and caring.

One lesson I have learned from my various experiences in therapy is that it can be difficult to find a therapist who is an optimal match. I have had both positive and negative endings to therapy relationships, and the negative ones have been very painful, ending with impasses that were irreparable despite the best efforts of both of us. These negative experiences shook my faith in psychotherapy for myself, even as I continued to practice successfully with my own clients. However, after time passed I found myself ready to take the step of vulnerability and trust again, and I have gained something from each experience including those that ended without mutual understanding and resolution.

Another lesson I would pass along is that psychotherapy is only one of many paths to increasing our self-awareness and to integrating confusing or conflictual parts of ourselves. I have benefitted from mindfulness and meditation practices, somatic practices like acupuncture and chi gung, relationships with wise mentors, intimate friendships, and membership in a spiritual community.

Regardless of your own experiences with personal psychotherapy, I encourage you to stay open to opportunities and relationships that will contribute to your journey as someone who heals and is healed with others.

My first fear as a new therapist, and the fear of every new therapist I have trained or supervised, was that there would be silence in a session. At the beginning of our training we live in dread of the conversation getting stalled and not knowing how to get things going again. Over time, if we are fortunate to have skilled, compassionate trainers and supervisors, we learn that silence can be an important part of therapy for some people at some times. The universal nature of this fear has led me to reflect on what it is about silence that feels so scary and how there are many nuances to silence between two people that range from unbearably tense to deeply intimate.

In reflecting on my own fear of silence as a new therapist, I begin with my family background. I grew up in a family that didn’t speak directly about emotionally charged issues or any type of discomfort. I knew my mom was upset when I heard the pots and pans in the kitchen clanging with more than the usual amount of force and noise. She was silent but the house wasn’t. I remember being unable to speak about the many thoughts and questions I had about my interpersonal world around me, and I didn’t know how to start a conversation or keep it going with someone I didn’t know well. When I sensed a wide gulf between what I felt or thought inside and what I was able or willing to express to others, I felt tense, awkward and embarrassed. That was my worry as a new therapist: that I would again be faced with a moment of wanting to say something but not knowing what to say or how to say it. I told myself I was afraid of letting down my client, but I was actually more afraid of the feelings of self-consciousness and shame that were familiar to me in moments of silence.

After I had developed the requisite skills for handling many therapeutic dilemmas including becoming comfortable with silence, I remembered that I actually had an equally powerful but contrasting experience with silence in my family. My maternal grandfather was a quiet man. He was a reserved Midwestern man from a farming family. My memories of him contain few if any words but are filled with a sense of being valued and cared for. I always felt special in his eyes, not because of what I had accomplished but simply because I was his granddaughter. It’s hard to describe how he did this, but I felt his presence and attention without expectation or agenda. In this way, my grandfather prepared me for the intimacy of silence in the therapy room that goes beyond words and that allows for the emergence of deep feelings that need space and time to come to light. I never felt hurried by him, and I can embody that patient attention when I sense my client is holding a memory or emotion that is waiting to be expressed though neither of us knows in advance exactly what it is.

In my years of practicing psychotherapy, I have had many poignant and sometimes painful conversations with clients that have included words, tears, and moments of silence. My grandfather is still with me in those moments, as I find the strength that goes beyond words. I hope my reflections lead you to think about the different experiences you have had with silence outside the therapy relationship and how they have shaped your comfort and fears about sitting in silence with a client.

I have been working with a client for about six months, and he doesn’t seem to be making much progress. Lately I’ve been feeling bored in the sessions, and I think maybe I should stop seeing him or refer him out for a different type of therapy or a group of some kind. He comes every week and hasn’t expressed any dissatisfaction with therapy, but I have started to dread the sessions.

This situation brings up the issue of using our personal responses, or countertransference, to the client to make decisions about the progress and process of therapy. A previous blog addressed this topic in terms of understanding the client. This post will look at how our personal responses help us understand ourselves. The tasks that foster professional development and identity are covered in Chapter 14 of my book.

The term countertransference is used to describe the feelings that arise in us during psychotherapy, and it is an important tool in the therapeutic process. There are many potential meanings to your feelings of boredom, and I’ll review several. Self-reflection on your own, with your supervisor or consultant, and with your personal therapist will guide you to the meanings that apply to your experience with this particular client. I start with the assumption that your boredom is an indication of a difficulty with this client that hasn’t emerged directly in your awareness, and I’ll suggest some areas to explore.

The first area for exploration is whether you are experiencing emotional responses to your client, in addition to boredom, that may bring you discomfort. In your next session, notice the full range of emotions that are present for you. You may notice frustration, aversion, fear, or other emotions that you judge as incompatible with your therapeutic role. Your boredom may be covering other more intense emotions that are unpleasant or uncomfortable but warrant exploration in supervision, consultation, or personal therapy. The client may remind you of a difficult situation in your personal life or with a previous client, and it will be helpful to differentiate that past situation from your present one.

A second area to examine is your interpersonal style regarding confronting or avoiding areas of potential conflict. If you tend to avoid discussions about difficult topics, your boredom may be a manifestation of that avoidance. Reflect on the therapeutic process with this client, and look for obstacles that may have arisen between you. Example are times when the client did things that undermined the therapy, when he externalized responsibility for his depression, or when he subtly devalued the steps you and he have taken toward progress. If this is the case, it will be necessary to find a way to address these obstacles directly rather than to withdraw.

A third area for reflection is whether you are feeling dissatisfied in other aspects of your work. If so, your dissatisfaction may be reflected in feelings of boredom with this particular client. For example, you may be scheduling more clients in a day than is comfortable, your employer may have changed some administrative requirements in ways that feel unnecessarily burdensome, or you may have agreed to see this client at an inconvenient time. If any of these factors are present, your boredom may express your need to address your work habits or agency requirements.

I hope these suggestions give you some ideas for how to understand the meaning of your countertransference responses, which contributes to your self-knowledge and professional development. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

I have been working at an agency job for a year and have been seeing a number of clients for six months or more. I’m looking for another job, and I’m wondering how much notice I should give at my current job in order to allow enough time for termination with my clients.

The topic of termination is covered in Chapter 13 of my book, including planned and unplanned endings that are initiated by the client or the therapist. The situation you describe is one in which you will be initiating the termination process with clients who may or may not have completed their treatment. It is a good idea to think ahead to the impact your job change will have on your clients so you can do as much advance planning as possible.

I recommend thinking about three tasks to be addressed: reviewing the treatment progress and relationship, anticipating future needs for treatment, and saying goodbye. These tasks are discussed in more detail in a previous blog. Another blog discusses the importance of processing your feelings about ending with your clients, preferably before you begin the termination process with them.

Usually it is ideal to allow 4-6 weeks for a termination process with clients you have seen for six months or more and 2-4 weeks for shorter term clients. If you work in an outpatient setting, always assume that some of your clients will miss one or more sessions during the ending process, making it advisable to have a longer rather than shorter time to end. When making a job change, however, you may not be able to give your clients more than 2 or 3 weeks notice, depending on the circumstances of your job search and any break you plan between leaving one job and beginning another. I’ll discuss here how you can handle the three termination tasks mentioned above in this compressed period of time.

The first issue to keep in mind if you are ending treatment of six months or more with 2-3 weeks notice is that the ending will inevitably feel somewhat incomplete. Since you are initiating the ending, you may feel a degree of guilt which could lead you to minimize the discomfort of the ending for both you and the client. It will serve both of you to acknowledge that you would like to have more time to say goodbye. In addition, you will be ending with all of your clients at the same time, which will bring up a lot of emotions for you, while you are also saying goodbye to colleagues and supervisors. Anticipate the emotional work this will require of you and use your support system to help with your own need for processing the endings of these relationships.

A second issue to consider is that some of your clients will miss their final scheduled session, so begin the termination discussion at the time you let them know you are leaving, even if you plan to meet another one or two times. Since the clients won’t be expecting this news, you’ll need to give them time to take it in before talking about it. I recommend beginning the session by telling them that you’re leaving, with a simple statement like “I’d like to start our session today by letting you know that I’ve taken another job and will be leaving here on (date). I’d like to take some time to talk today about ending our time together, though we’ll also be able to do that in our next (1 or 2) session(s) as well.” Then wait for the client to respond, and if she/he moves quickly into another issue about her/his life, look for another opportunity later in the session to come back to the termination process.

When the termination process is brief, it is often helpful to give the client a written note with some of your thoughts about the treatment as a supplement to your discussions in person. Many clients lack the experience of talking directly about the ending of a relationship, and this often leads to avoidance and denial of feelings of loss. You may not have an opportunity to share everything you would like to say to the client in a session, so writing a note ahead of time gives you a chance to express yourself more fully. It may also be easier for the client to take in your thoughts at a later time. If the client misses the session in which you plan to give her/him the written note, you can consider sending it by mail.

One of the three tasks I recommend addressing during termination is the client’s future needs for treatment. When you are leaving your job, the client’s continued treatment will be dependent on another clinician’s availability at your agency so you will discuss this issue differently based on those circumstances. The other two tasks—reviewing the treatment and saying goodbye—are solely about your relationship and aren’t dependent on the agency arrangements for the client to continue or end. Although there may be a lot to say, it is possible to accomplish these two tasks in a relatively short period of time if you prepare for these sessions by thinking about each client individually and what you can say about the nature of your work together and how you feel about ending. It is often meaningful for the client to hear how you have been affected by the work.

These recommendations will help you in managing an unplanned ending with clients with thoughtfulness. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

I am working with a client who is taking an anti-depressant prescribed by a psychiatrist. She has begun to show symptoms of euphoria, rapid speech, and decreased need for sleep, which makes me wonder if she should be taking a mood stabilizer. She has signed a release giving permission for us to share information, so I’m wondering how to approach this issue in a phone call with the psychiatrist.

This is a good example of a case in which coordination of client care is very important. You probably see the client more often than the psychiatrist, so it’s understandable that you would see the emergence of these symptoms first. Communicating with your client’s prescribing psychiatrist will be beneficial to your treatment as well as possibly influencing the psychiatrist’s decisions. The topic of case management is covered in Chapter 12 of my book. Case management includes coordination of care and contacts you have with other professionals or family members.

The first issue that clinicians often face when contacting a psychiatrist is the difficulty of scheduling a time to talk. If s/he has an assistant, you may be able to schedule a time relatively easily, but if s/he works independently it is likely to be more challenging. I recommend leaving a message introducing yourself, stating you have a release you’re your mutual client giving permission for you to share information, and giving some times that you’re available. It is wise to include late afternoon or early evening times if possible, since s/he may return calls at the end of the day. If you don’t get a return call within two or three days, it’s fine to leave another message. There may be some back and forth exchange of messages before you’re able to speak in person, so be persistent.

Before you have the phone conversation, take some time to plan what you want to say and what you want to know. Separate the information you wish to provide from questions you have for the psychiatrist so you’re clear about your goals for the conversation. In this case, you want to share your observations about the client’s symptoms and you want to ask about the psychiatrist’s diagnosis and observations. There may be additional information that is helpful to exchange, but keep in mind the HIPAA requirement to share the minimum necessary information. Do not share details of the treatment or the client’s history that are not relevant for the psychiatrist’s prescribing decisions.

Before the call, notice your feelings in anticipation of the conversation. Some clinicians feel intimidated by psychiatrists, and this can lead to defensiveness or a lack of clarity. Work to prepare yourself for a collaborative, professional discussion. Since your primary goal is to let the psychiatrist know about the client’s recent symptoms, you might plan to start the conversation by saying “I have observed some changes in XX’s symptoms lately, and wanted to pass along that information. She has appeared euphoric and reports a decreased need for sleep. I’ve also seen some rapid speech that seems to indicate a flight of ideas. These changes have taken place over the last couple weeks, and I thought I should let you know.” It is best to refrain from making any suggestions about prescribing, since that is outside your scope of practice and may be off-putting to the psychiatrist. Stay with an objective report of what you have observed and what the client has reported. Keep your questions in mind, so you can ask those before the end of your conversation if they don’t come up naturally. The conversation may end with a plan to talk again in a specified period of time or with a more open ended agreement to check in as needed.

I recommend that you create a progress note documenting each time you have contact with another professional about your client. It provides evidence in the record that you have followed the standard of care, and it also gives you a reminder of the details of the conversation which may fade with time. A paragraph is usually long enough to summarize your conversation and any plan that resulted from it.

I also recommend that you talk with the client about your conversation with the psychiatrist when you meet for your next session so she feels included in the communication. A short summary reporting what you shared and what you heard is sufficient, followed by asking if there is anything else she’d like to know about your conversation.

You are now prepared to talk with the psychiatrist in a way that will benefit your client. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

I have been seeing a client in therapy for over six months. He was very depressed when he came in, and his depression has improved though he still scores in the mild range on the Beck Depression Inventory. I’m not sure what more to do to help him continue his improvement. It seems like therapy has reached a plateau.

The topic of the therapeutic relationship is covered in Chapter 11 of my book, which reviews different aspects of how therapy evolves over time. In this case, you report significant improvement followed by a period when the symptoms are remaining stable. I can recommend several things to consider at this point, to help you and the client understand the meaning of this plateau.

I would first suggest that you talk with the client about your perception that his symptoms have reached a plateau. He may be aware of subtle changes that aren’t reflected in his BDI score, indicating that change is still taking place during this period. If he does report that the pace of change has slowed, you can ask him how he understands this and engage in a collaborative discussion that may result in some insight into the next phase of therapy. Two specific areas for discussion would be his feelings about the changes that have occurred since he began therapy and an examination of the function his remaining symptoms may serve in his life.

Discussing your client’s feelings about the changes he has made may identify some ambivalence or some discomfort with what is unfamiliar to him. Although improvement in depression is desirable and is probably the primary goal you and he have worked toward, there are times when change can feel uncomfortable or even frightening. If he is handling situations differently, he may need some time to adjust to his new approach or a new way of thinking about himself and others. It’s possible you don’t need to do anything more; instead this pace may fit your client’s needs.

If your client indicates that he feels stuck or stalled in his progress, I would recommend that you reflect together on the function his symptoms may serve. In some cases, clients come to recognize that their identity is associated with being depressed or that they are repeating a pattern from their family of origin or that being free of depression may increase the expectations they and others hold for themselves. These factors are usually outside of awareness, so this examination may unfold over several sessions. The client’s history and current life circumstances may provide you with some ideas of how depression may serve a purpose. For example, he may feel closer to a depressed parent or sibling when he is also depressed or he may be avoiding the pursuit of a different job or entering into a new relationship.

It is possible that discussing these issues with your client will result in expanding or shifting the focus of therapy to incorporate your perspective on this plateau of symptoms. You might begin to talk more about the client’s sense of identity, his childhood experiences, or conflicts in his work or relationship life. You also might find that the client needs to learn and use different strategies for managing his symptoms in light of the new insight you and he develop together. This isn’t a matter of you figuring out what to do, but you and the client working together to discover what he needs to continue his healing.

I hope these ideas are helpful in understanding a period of slow change in therapy. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

How can I protect the notes I take during supervision and consultation from being seen by a client who requests her record? I find the notes valuable in planning for sessions and for tracking my own countertransference, but I don’t want clients to be able to see my notes.

Your question refers to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) which make all health records accessible to clients upon request. There is an exception, however, that is important to know in creating and maintaining documentation for psychotherapy. Chapter 10 of my book covers issues related to HIPAA and other issues to consider in clinical documentation.

HIPAA defines progress notes as part of the treatment record which must be provided to the client and psychotherapy notes as the property of the clinician and kept outside of the treatment record. I’ll define each of these terms more specifically and describe the practices that make it clear whether you are creating a progress note or a psychotherapy note.

Progress notes are part of the client record and are used to document the service you provided. Generally they include information about the date, time, location, and length of the session; who attended; the client’s mental health status in terms of symptoms and functioning; your interventions and the client’s response; assessment of any risk or danger; progress toward treatment goals; and plan for continued treatment or referrals. Progress notes are written in objective, professional language and are relatively concise. These notes may be requested by a third party funder to support a billing claim or as part of a periodic audit. If the client requests her/his record, you are required to provide copies of the progress notes along with other clinical documentation such as assessments and treatment plans.

Psychotherapy notes, as defined by HIPAA, contain material that is clinically relevant to the clinician but not required to document the service provided. Examples of material that is appropriate for a psychotherapy note rather than a progress note are impressions or hypotheses, details of the client’s history or therapeutic interactions that are meaningful but not necessary for a progress note, descriptions of your personal countertransference responses, and notes from supervision or consultation.

Based on these definitions, your notes from supervision and consultation are psychotherapy notes and are not part of the client’s record. However, you need to use care in how you keep the psychotherapy notes in order to be clear that they are your property and kept for clinical purposes only. I recommend keeping your psychotherapy notes in a separate folder rather than keeping them in the client’s chart. This makes it less likely that there will be any misunderstanding or confusion if the client does request the record or gives permission for you to release the record to a third party. If you work in an agency, you may not receive the request, and another staff member may not be able to distinguish between progress notes and psychotherapy notes if they are kept in the same chart. If you receive the request yourself, it may be difficult to separate them without the time consuming step of reading each individual note.

There are no requirements for keeping psychotherapy notes for a specified period of time, in contrast to legal and ethical requirements for keeping client records for seven years or more after the end of treatment. For this reason, you may wish to destroy your psychotherapy notes once they are no longer clinically relevant. You may also wish to keep the psychotherapy notes free of any identifying information that could fall under the HIPAA definition of Protected Health Information (PHI). If you use initials only or a number code that is known only to you, it is more clear that the psychotherapy notes are not part of the client record.

I hope this clarifies the question of what notes must be disclosed to the client and what can be kept for your own use. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

I was contacted recently by the mother of a 10-year-old girl who has been showing symptoms of anxiety. The mom said her father died two months ago and the whole family has been affected by his death. She asked if I can see her 10-year-old daughter weekly and also see the family (including mom, dad, and older brother) every few weeks to help them through their period of grieving. I’m not sure how to respond to her request.

This situation illustrates one of the first questions we face in beginning with a new case: “who is my client?” or “what is the unit of treatment?”. You need to define the unit of treatment in order to decide who will participate in therapy sessions and how you define your therapeutic relationship with one or more members of the family. Chapter 9 of my book is devoted to the topic of treatment planning, which includes decisions about the therapeutic frame and structure, the client’s goals for change, and the therapeutic interventions that will facilitate that change.

When a child is involved in the initial request for therapy, your client may be the individual child with the parents participating in collateral sessions or may be the family. Your decision about the unit of treatment will affect how you structure the sessions, in terms of who participates and how frequently, but more importantly it will affect your treatment goals and interventions. Let’s look at how you might make this decision, assuming that you have experience in conducting both individual child and family therapy.

The first step is to recognize that you can take time to reach a decision about how to approach this case. You can respond to mom’s request by telling her that you would be open to seeing both her daughter alone and the family together, but that you would need to learn more about them in order to recommend the best way to work with them. All cases begin with an initial assessment, but the complexity of this situation make it preferable to explicitly begin with several sessions of assessment. This would give you a chance to meet with the family in different combinations, gaining information and making observations about them individually, as a unit, and in different subgroups. I would recommend one or two individual sessions with the daughter, one or two sessions with the parents individually and/or together, one family session, and possibly an individual session with the older brother. At that point, you would be able to determine the best way to proceed.

As I mentioned above, answering the question “who is my client?” primarily refers to how you define your relationship with the family. If you decide that the 10-year-old daughter is your client, your treatment goals and interventions will be focused on her symptoms and you will hold sessions with her parents and possibly the whole family in order to facilitate her progress. If you decide that the family is your client, you will develop treatment goals for the family as a whole and any individual sessions with the daughter or other family members would be in the service of helping the family grieve and reach some resolution of their loss. Your interventions would be oriented toward strengthening and improving the communication patterns and relational dynamics within the family rather than being targeted toward the symptoms or behaviors of any individual in the family.

Answering the question “who is my client” is an important step at the beginning of treatment. It deserves time and attention in order to make sure you will be successful in addressing the presenting symptoms and issues. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.